Robotic Surgery

The frontiers of medicine and surgery expand continually – what was once considered science fiction is rapidly becoming fact. Perhaps nowhere is this phenomenon more accurately depicted than in the field of robotic surgery. The first relatively simplistic robotic procedure was performed in 1985; today, robotic surgery is becoming a procedure of choice. In Chattanooga, robotic surgery is prominent and the surgeons who use it – recognized nationally and around the world as experts in their specialties – perform procedures at major medical facilities in the city and surrounding areas.

Advanced Technology-improving Patient Outcomes

By Mike Haskew

Today’s standard of care in robotic surgery includes the da Vinci® Surgical System developed by Intuitive Surgical. The da Vinci system consists of a surgeon’s console, a high resolution 3-D vision system, and a patient-side cart that provides either three or four robotic arms (depending on the model) – two or three arms that secure the instruments used for surgery and one endoscope arm that provides the surgeon with complete vision of the anatomy – that execute the surgeon’s commands. The surgeon controls the robotic arms from the console. Each of the arms work through tiny incisions, or operating ports, rather than larger incisions required for traditional surgery.

During a surgical procedure, the surgeon maneuvers the arms with precision using two foot pedals and two hand controllers while viewing operating images that are enhanced, refined and optimized using image synchronizers, high-intensity illuminators and camera control units.

More than 900 hospitals around the world currently utilize the da Vinci® Surgical System and to date, tens of thousands of procedures have been performed. While the cost of a da Vinci system is substantial – $1.75 million or more – the benefits for both physician and patient are readily apparent.

Dr. Lee Jackson, a urologist and prostate cancer surgeon affiliated with Memorial Health Care System, has performed over 700 robotic prostatectomies. Over the course of the last five years, Jackson has been a leader in the use of robotic technology performing robotic surgeries for cancers of the prostate, bladder, kidney and adrenal.

“When I do a prostatectomy, I operate in a space about two or three inches across, so it is very small and confined by bone,” he explains. “Moving my wrist around outside is a great advantage. If I had been doing open surgery, most of the time I would not have been able to see what I was doing. A lot of the traditional surgery was done by feel. Now, although I cannot feel, I can see through high definition magnified up to 15 times. In newer units, the camera and light are within a few millimeters of where you are working. If you are doing a complicated, precise task, you would rather be able to see well than to work just by feel and basically be blindfolded.”

Jackson identifies the robot as one more instrument in the laparoscopic surgery process, but it has a distinct advantage. “My hands fit into straps, and as I move my hands the robot mimics my movements,” he says. “With pure laparoscopic surgery, the surgeon is holding the instruments. The robots have wristed motion and move just like your hands and give you great range of motion.”

In the case of prostate cancer surgery, active men in their 40s, 50s and 60s are often able to return to work within two weeks of the operation, as opposed to as many as eight weeks with more traditional surgical techniques.

“We look at outcomes, including margin status – how well we did in getting all the cancer out – then recovery of urinary control and potency,” Jackson says. “Those numbers are pretty much identical to open surgery, but personally having done open and robotic surgery, I think robotic is a better operation. There is less blood loss, and more nerves are preserved. What robotics has offered the patient is a reduced recovery time.”

Dr. Amar Singh, a urologist and robotics specialist with Academic Urologists at Erlanger Medical Center shares the same enthusiasm for robotic surgery. “Patients experience a quicker recovery from surgery because of the small size of the cuts required,” he explains. “There is less need for blood transfusions, less pain and an earlier discharge from the hospital. For the physician, there is three-dimensional vision that includes depth perception; the ability to replicate the movements of the wrist inside the body through small cuts; great magnification; and overall surgical precision.”

A urologist with a specialization in urologic oncology, Singh also performs robotic surgical procedures related to cancers of the prostate, kidney and bladder. In each case, he says, specific benefits are realized. For instance, prostate cancer patients often experience a more rapid return of urinary control and sexual function than with traditional surgical techniques. In kidney cancer surgeries, robotic procedures may result in better partial preservation of the kidney and fewer complications. Robotic surgery for bladder removal and reconstruction often result in less pain and bleeding, with a more rapid return to normal activity.

“The technology is continuously improving,” says Singh. “It is integrating various imaging modalities into the surgical tools, and the size of the instruments will likely get smaller. Some of the newer prototype robots use one small cut to do the entire operation, as opposed to five or six small cuts that are used with current technology. Miniaturization of the surgical instruments and integration of modern medical tools into this technology will help the surgeon provide better care for patients.”

Urologic cancers comprise up to 50 percent of all cancers, including those of the prostate, kidneys, bladder, testicles, ureter and adrenal glands, according to Singh. Each of these, he says, can be effectively treated with robotic surgery.

Recognized internationally as an expert in gynecologic oncology, Dr. Donald Chamberlain has performed nearly 700 robotic cases since 2003. Additionally, he has traveled extensively while teaching other gynecologic oncologists how to use the da Vinci Surgical System. When President George W. Bush visited Chattanooga in February 2007, Chamberlain provided him with a demonstration of the system.

“Physicians are able to perform much more difficult surgeries with robot-assisted minimally invasive surgery than with traditional laparoscopic surgery,” says Chamberlain, who has performed a large number of robotic procedures at Parkridge Medical Center. “Surgeries that otherwise would require very large incisions, with the associated long hospitalizations and difficult recoveries, are now able to be treated without prolonged hospitalizations and recoveries are much shorter.

“Robotic surgery is a form of laparoscopic surgery in which several tiny incisions are used to enter the abdominal cavity, which is then filled with carbon dioxide gas,” Chamberlain explains. “Surgical instruments are attached to the robot and are controlled at the console, where the surgeon has 3-D vision and very fine dissection ability.”

According to Chamberlain, major gynecologic oncology surgical procedures performed with minimally invasive robotic surgery include: endometrial cancer staging surgery; cervical cancer; radical hysterectomies; and early ovarian, primary peritoneal and fallopian tube cancer staging surgery. In each case, benefits include improved surgical results, more rapid recoveries and minimized blood loss. Additionally, chemotherapy can also be started sooner due to a quicker patient recovery time after surgery.

In addition to fewer puncture sites, Chamberlain envisions future robotic surgery improvements that include a second operating console to allow a skilled surgical assistant or second surgeon to participate in more complex or difficult operations, nontraditional entry sites for instruments, and remote surgery.

Chamberlain explains: “Rather than making incisions through the abdominal wall to gain access to the abdominal cavity, natural orifices like the mouth, through the stomach, or the anus, through the rectum, will be used. This will eliminate all abdominal scarring.

“There are usually not enough expert surgeons to go around,” he continues. “With current technology, an ‘expert’ surgeon can perform the actual surgery from miles away while the patient’s local surgeon is at the patient’s side assisting the ‘expert.’”

Clearly, if given the choice, patients will often opt for robotic surgery over more traditional procedures. “If you want your surgeon to have more control, or if you want the surgeon to see better, then you want robotic surgery,” states Dr. Anthony Harbin, an obstetrician/gynecologist who founded the North Georgia Women’s Center in 1989 and has performed a number of robotic surgeries at Hamilton Medical Center in Dalton, Ga.

“Patients have less pain, less blood loss, faster recovery, and no additional charges from the hospital or the surgeon,” says Harbin. “The surgeon can see better, is in a more comfortable position, and is better able to deal with unexpected findings.”

Harbin often performs robotic surgery procedures. Among these, the most common include hysterectomies, myomectomies (the removal of tumors from the uterus) the removal of endometrial growths (uterine tissue attached to organs or other locations outside of the uterus), repair of vaginal prolapse, and tubal reanastomosis (the reversal of tubal ligation). He says that better vision, along with improved precision and dexterity, allow him to complete procedures with improved safety and a better overall experience for the patient.

“Seeing the surgical field with 3-D vision is superior to the 2-D vision we had with conventional laparoscopy,” he added. “The increased precision results in less post operative pain and a speedier recovery, which is tremendous. For example, I removed a 7.5-centimeter tumor from a woman’s uterus some time ago. That was on a Friday, and she was back at work Monday. I operated on another woman and called her home late that day to see how she was doing but never did get an answer. She felt good and had gone on to the store and to church with her husband.”

“The future is exciting,” Harbin says. “They are working on smaller instruments and instruments with flexible arms, which will expand the uses of the technology. I may have to explain to my grandchildren why physicians once used to cut people open for surgery.”

A brave new world of robotic surgery may be on the horizon. Today, robotic surgery reduces the potential for human error due to such natural occurrences as hand tremors. Tomorrow, the development of surgery performed by robots alone may, in fact, become commonplace. In the spring of 2006, an operation to correct cardiac arrhythmia was performed by a fully autonomous robotic surgery system with a database of 10,000 operations for its “experience” level.

However, while such technology may indeed emerge in the future, current robotic surgery systems are not capable of making decisions and function only as precision replicators of the surgeon’s hands.

“The biggest benefit of the da Vinci robotic surgery is that people recover much faster, and they can return to normal activity, including their work, much quicker,” adds Jackson. “Robotic technology is and will continue to improve so that a greater variety of disciplines, such as ENT (ear, nose and throat) doctors, colorectal surgeons and others will be using it. In five years, I believe that the majority of all urologic cancer surgeries will be performed using robotic surgical systems.”

For physicians and patients alike, the future of robotic surgery presents exciting possibilities. Generations to come may well experience a level of surgical expertise, precision and recovery that is far beyond what can be conceived of today.

Mike Haskew is a graduate of the University of Tennessee at Chattanooga and holds a degree in history. He is a native Chattanoogan and is currently an executive with First Citizens Bank.